Introduction - Adam

Adam is now aged 9, and in the fourth grade. His parents are very worried
about him. He is struggling with maths, his handwriting is poor, he is
disorganised and distractible, his social friendships are slipping and Adam is
becoming quite anxious. Although Adam can discuss and negotiate at quite an
advanced level, his behaviour tends to be rather egocentric, toddler-like.

The story of Adam began quite differently. He seemed to be an intelligent boy
early on. He was bright, happy and learned to talk well from an early age. After
meeting with Adam, people would comment what a clever child he was. He loved to
socialise, loved to learn and initially his parents were hopeful and proud.

The situation began to change not long after he began at school. Handwriting
was difficult, and 'getting things done' a chore. Learning to read was not too
difficult - in fact he is a fluent reader. The only concerns relate to his
comprehension of what he reads.

Adam's enthusiasm began to wilt late in the second grade. In the third grade
he started to say things like 'I'm dumb'. His written output was the most
obvious weakness - his letters would vary in size and shape, his spatial
planning of words and sentences on paper was poor and the whole act of putting
words on paper a terrible chore. The difference between how well Adam could
talk, and what he could put on paper was most obvious.

The dilemma for Adam and his parents is that of a boy whose development began
with such promise, yet now, midway through the primary grades, he is struggling.
Not only is the present difficult, but looking towards the future, his parents
can only see matters worsening.

Diagnosis of Non-Verbal Learning Disability (NLD)

As with all developmental diagnoses, NLD is a criteria
based diagnosis. To understand the diagnosis, it is useful to work through
each criteria in turn:

Criteria 1: A statistically uncommon phenomenon.

For NLD, the statistically uncommon phenomenon is the discrepancy, or
difference between different intellectual skills within the same
brain. Specifically, children's ability with language related tasks is
significantly better than their abilities on non-language testing.

Probably the most common intellectual assessment is the WISC (Weschler
Intelligence Scales for Children). Results on this IQ test are broken into two
broad groups - the Verbal scale, and the Performance
scale. A statistically significant difference would meant that the verbal result
is 15 points (one standard deviation) higher than the performance.

Sometimes, even with the disorder present, the assessment will not reveal
this discrepancy until the child is old enough. This should occur by Adam's age
of 9 to 10 years. Other tests which may be useful in revealing this discrepancy
are discussed later in this document (tests).

Criteria 2: Impact on the child's life.

A learning disorder means that the child is struggling to achieve, in the
area of concern, what might reasonably be expected for that child's overall
intellectual ability. In the case of NLD, the areas of difficulty are diverse,
and may vary considerably from child to child. They include:

Maths: Often children with NLD can achieve with maths in the
early grades. It may not be until later in primary school that they
struggle. The problem is maths concepts - they have difficulty
understanding what the operations are trying to achieve, and, as a result,
are very reliant on the step-by-step processes.

Handwriting. Getting thoughts onto paper can be a problem
from the very start. This is because children can have trouble automating
letter formation (so they always have to think about it), trouble organising
the letters and words on paper (with varying size and placement), and
trouble planning the whole process of putting their thoughts into sentences
and words to write.

Organisation. Organisation means seeing large jobs in terms
of all the little jobs. Cleaning the bedroom, for example may be to complex
and overwhelming. By contrast, just picking up dirty clothes may be
achievable. Children with NLD have trouble keeping the large job in mind as
they work through the smaller jobs within that task.

Attention. Many children with NLD have difficulty
maintaining attention. For some this is limited to situations where the
material is difficult (or uninteresting).

Social understanding. Often children with NLD are
enthusiastic and successful at socialising in the earlier years. As with
maths concepts, it is not until the social demands exceed their abilities
that they struggle. This may not happen until the later primary grades.
Specifically they struggle to read the non-verbal information in peoples
facial expressions, body language, tone of voice, choice of words etc. As a
result, they miss the emotional states behind the words, and do not pick up
more subtle messages such as sarcasm.

Anxiety and fear. Anxiety is our brain's way of holding out
a red flag that says 'beware - something is going on that could be a
problem'. For children with NLD, although they can communicate verbally
with ease, their underlying understanding of the world may be relatively
limited. As a result, they can feel a recurring sense of confusion. In
social and other situations this confusion generates anxiety. In fact, as
children become adolescents and adults, management of their needs is often
dominated by the management of anxiety.

Non-verbal and spatial thinking. Many of our thought
processes occur non-verbally, or entirely without words and language. A
mechanic, for example, exploring problems with an engine, may be thinking
about that engine in completely non-verbal terms - imagining it, picturing
it. He may know what is wrong, yet struggle to put this understanding into
words. For a child with NLD the situation is exactly the opposite. For some
children, even basic concepts such as time and money may be difficult.
Abstract scientific concepts such as the weather may be a struggle. For
others the impact is more spatial - they get lost easily, have trouble with
maps, and have difficulty with team sports where direction and movement are
important.

Motor co-ordination. Some children with NLD are clearly
clumsy. Others may be well co-ordinated and struggle only in team situations
where there is continuous and complex information about people and
directions to be understood.

Criteria 3: No alternative explanation.

If a child is struggling in several of the areas outlined above, and to a
degree greater than what would be expected for their overall intellectual
ability the next step is to ensure that there is no alternative explanation.
This is achieved by considering each of the alternative possibilities.

Attention Deficit. Sometimes just having ADHD can lead to
the pattern of problems outlined above - particularly if small non-verbal
weaknesses are present which become amplified by the attention problems. The
way to be sure of this is to treat the ADHD and see if children improve.

Intellectual Disability. Sometimes, if children are clever
verbally, early intellectual assessments may overestimate their IQ. Only
later testing will reveal their true abilities.

Anxiety / abuse. Children who are temperamentally anxious,
or who are in abusive situations causing anxiety may have difficulty in the
areas outlined above. As with ADHD, for these children, if their anxiety
settles their skills can usually catch up to some degree.

Lack of opportunity to learn. For a few children, the reason
why they struggle with maths and handwriting is that they never learned the
basics properly. With some additional support, these children usually catch
up.

Asperger Syndrome. The difference between Asperger Syndrome
and NLD is not clear cut. Although children with Asperger syndrome are
fluent verbally, this does not mean that they have trouble with maths,
handwriting, attention and organisation. If we are unsure, and social skills
are the greatest problem, we will choose the diagnostic category that best
helps understand the child and leads to the best level of support.

Semantic-Pragmatic language disorder. This is a type of
language problem where more complex language is impaired, leading to
difficulties in comprehension and the social use of language. As with
Asperger Syndrome, there are no clear boundaries with NLD, except that
semantic-pragmatic disorder does not usually include problems with maths,
handwriting, organisation and attention.

Criteria 4. A consistent pattern.

As with all developmental disorders, what we are looking for here is a
consistent picture over time and different contexts. With NLD this is a little
tricky because children often use their language skills to compensate their
non-verbal weaknesses up to the early primary grades. This gives the false
impression that there was no problem until school years.

A brief history

The NLD pattern has been known for many years. Adults who suffer damage to
the right side of their brain often experience the same pattern of problems -
compared to their intelligence and verbal skills, they struggle with maths,
social skills, handwriting, organisation, attention, spatial motor planning and
the emotional consequence of anxiety.

Knowing this pattern from adult head injuries, some researchers have called
NLD the Right-Hemisphere Learning Disability Syndrome. This is clearly true for
some children - who, on neurological examination, show differences between their
left and right sides. For other children this is not so clear, and we can only
presume that the problem lies within the right side of their brain.

Another line in history has been the 'Developmental Gerstmann Syndrome' which
included the 4 problems of handwriting (dysgraphia), poor maths (dyscalculia),
confusion about left and right, and difficulty localising touch to specific
fingers (finger agnosia). The word Developmental implies that the cause was
disordered brain development rather than acquired brain damage. This diagnostic
term has now fallen out of common use.

The core problem

Most of the symptoms of NLD can be understood as the consequence of a single
type of problem within the brain. This is a level of impairment in the ability
to take multiple pieces of information and pull them together to form a single,
integrated 'picture'. This is the ability to see the 'whole' as the 'sum of the
parts', or to understand how many pieces of information fit into a single
explanatory pattern.

To take the example of learning maths. What we do is provide children with
many examples of a new concept (e.g. fractions). Children with good non-verbal
understanding learn the concept quickly, from only a few examples. They can then
use these concepts to work out the answers to new questions. Children with poor
non-verbal thinking skills may learn how to do the problem but struggle to get
that 'click' of understanding what the issue (in this case fractions) is all
about. They remain confused about numbers above and below the line. They can
answer questions by following the step-by-step processes, but cannot use their
understanding to answer questions that very in process.

Another example is social skills. As human relationships become more complex,
we rely increasingly on non-verbal information to journey through the maze. This
means using our knowledge of people (what they know, like), their facial
expressions, their gestures and body language, their tone of voice, their eye
contact, their choice of words and many other pieces of information. We put all
these pieces of information together to work out what that person is thinking,
feeling and wanting. NLD make the process of putting all this information
together difficult. Without knowing what others are thinking and feeling,
children may assume that others are thinking and feeling the same as themselves.

This same type of discussion can be applied to organisation (seeing the
overall task as the sum of many smaller tasks), and writing (seeing the
component pieces of letters, words, layout, sentences and message, and how they
all fit together).

Variations

It is important to note, as indicated above, that no two children who meet
this diagnosis criteria are the same. For some children the problem may rest
predominantly with their maths and handwriting. For others it may be more
organisation, attention, behaviour and social skills. For some the motor
problems are significant whilst for others they are non-existent.

One key variable in this variation is a child's overall intellectual ability.
Essentially the smarter children can use their intelligence to overcome some of
the underlying problems. This does not mean they fix the problem - just that
they learn to achieve the goals in other ways. With maths, for example, they may
memorise the rules, and use their verbal skills to quietly work their way
through maths problems, step by step, without a full understanding of the
problem itself.

Given this diversity in clinical manifestation, the question arises as to
whether there is any benefit in using this diagnostic label. The short answer to
this question is yes, but only if it significantly improves understanding of the
individual child. For further information on this question see diagnostic
labels.

NLD and Language Disorder

In some cases, particularly where there is no cognitive testing, NLD can be
mistaken for a language disorder. It is surprising that such a mistake can be
made (given that language is the strength for children with NLD), however the
problem lies in the highest and most abstract levels of language. Specifically,
when tested in isolation, the abstract problem language abilities are usually
poor. If there is no broader picture of the child (including their non-verbal
conceptual skills), the erroneous conclusion may be drawn that the child's
language is the problem.

NLD and Dyslexia (Reading Disorder)

Another unusual presentation of NLD, particularly in the earlier grades of
primary school, is that of a reading disorder (see dyslexia).
Children may be able to do the easier Maths just fine, and struggle with
reading. The reason they struggle with reading comes to the visual component -
recognising letters and whole words. This type of problem slows the acquisition
of a sight word vocabulary. Poor attention control can also be a contributing
factor - making it difficult to 'pull the skills together' that are necessary to
learn to read.

In this case, usually the picture changes over time. Children with NLD
usually learn to read, and as time progresses their writing and maths become
more problematic.

Medical Causes

It has been proposed (Professor Byron Rourke, Canada) that NLD is the result
of white-matter problems in the brain. White matter is the 'wiring' of the
brain, carrying information from one place to another. If this is not working
properly, he proposes, it interferes most with brain processes that require a
lot of communication from many parts of the brain at the same time. As discussed
above, this seems to be the core issue for NLD. Language functions do not need
much communication around the brain - they are tightly localised on the left
hand side.

This theory had not been proven. However it is clear that NLD can result from
medical conditions medical conditions which seem to cause damage to right
hemisphere function more than left. These include:

Hydrocephalus (where the increased fluid pressure inside the
brain may damage white matter more than grey).

Turners Syndrome. This is a genetic problem in girls where
they only have one X chromosome instead of two. This can alter brain
development, leading to a NLD pattern of problems.

Fragile X syndrome. This is another genetic disorder of the
X chromosome, usually manifest in males. It can alter brain development,
leading to different patterns of developmental problems including NLD.

Tumors, calcification, cysts, brain injury. Any process that
selectively damages the right side of the brain can lead to the clinical
picture of NLD. Rarely, cases have been described where damage was on the
left side in foetal development. Somehow, the 'left' functions were taken
over by the right side (so children could use language well) and the normal
right side functions were impaired.

Multiple Sclerosis, and other disorders of white matter.
These are very rare in childhood, and lead to many neurological problems.

Agenesis of the corpus callosum. This is where the major
communication fibres between the left and right side of the brain fail to
develop correctly.

Congenital Hypothyroidism. This is where the foetus is
deprived of normal amounts of Thyroid Hormone during the pregnancy.

Foetal Alcohol Syndrome. This syndrome is caused by alcohol
damage to the developing foetus.

Treatment for Leukaemia. The chemicals and radiation used to
treat Leukaemia in the brain can damage white matter.

Despite this list, for most children with NLD, we do not find a medical cause
for their developmental disability.

Psychological tests used in the diagnosis of NLD

Intellectual

Intellectual assessments attempt to test all the cognitive skills necessary
for academic success in school. These include language, memory, speed, attention
and non-verbal thinking. The resulting overall IQ score is the combined results
from all these different component tests. In addition to the overall IQ, results
are often organised into verbal and non-verbal (performance) scores. It is the
difference between these that suggests NLD.

Unfortunately children do not always fall neatly into this pattern of
results. Children with strong verbal intelligence can often use their language
skills to compensate for their weaknesses non-verbally. Specifically, they 'talk
themselves through' tasks that other children may achieve by pure visual
intuition. For this reason, a smaller split for younger children between verbal
and performance results is not necessarily evidence against an NLD.

Rey-Osterrieth Complex Figure

The Rey-Osterreith
Complex Figure (ROCF) was devised in 1941 by the Swiss psychologist Andre
Rey for the purpose of assessing perceptual organisation (how we integrate and
organise what we see) and visual memory in brain injured subjects.

A number of American neuropsychologists have found a way to use this test
with children. It is is particularly interesting because it examines the
processes children use in addition to the result they finally achieve. It can
show how children with NLD perceive and remember information piece-by-piece
rather than binding that information up into a single whole.

Wide Range Assessment of Memory and Learning (WRAML)

The Wide Range Assessment of Memory and Learning (WRAML), as the name
suggests, directly assesses memory and the ability to learn. Its use for
children with NLD is that it examines verbally and language information
separately from visual information. Of interest is whether there is a difference
between the two (i.e., children perform better on the verbal tasks).

Other assessments.

There is no single assessment that makes the diagnosis of NLD. It comes from
the total body of evidence. Other tests which may be useful include:

Academic Achievement. Tests such as the WIAT (Wechsler
individual achievement test) can give a fairly quick estimate of how a child
is performing in reading, spelling, writing and maths. These are
administered by psychologists.

Language function. Tests such as the CELF can give an
estimate of overall expressive and receptive language abilities. These are
administered by speech and language pathologists.

Visual Perception. Either psychologists or occupational
therapists have several tests that examine visual perception and visual
memory. One example is the Beery test of Visual-Motor Integration.

Executive Function. Neuropsychologists have a variety of
assessment tools to examine the planning, organisation and memory skills
that come from the frontal lobes of the brain

What happens over time.

The bad news with this disorder is that problems tend to worsen over time. As
the academic curriculum, and life in general (socially, organisationally)
becomes more challenging and complex, the difficulties for children with NLD
increase.

With maths, for example, there is often a ceiling to comprehension, a point
beyond which it becomes almost impossible to keep up with the curriculum. The
demands on writing, organisation and general conceptual understanding increase
in a cumulative way.

If the underlying disorder is not recognised and managed, the experience for
children can be frightening. As indicated above, the disorder already seems to
include a predisposition to anxiety. If not managed, the anxiety, fear and
depression can develop during adolescence and adult life into major mental
health problems.

What can be done?

The first step is to be sure the diagnosis is correct, and to gain a working
understanding of the problems it results in for the child. For parents this
process inevitably has a large emotional impact- see bereavement
and sorrow.

What can then be done for the child is outlined in a separate document nldtreatment.html